Topic 1 DQ 1
Hello Professor Derby and Class,
Major requirements for documentation of a new client must include informed consent, intake
assessment form, mental status exam, crisis intervention intake form, and all forms need to
include the client's name, date of birth, and any other necessary client demographics (Contra
Costa Behavioral Health, 2021). Major requirements of an ongoing client includes all of the
requirements for a new client as well as no harm/safety contract, inpatient referral form,
request/release of information form, treatment plan, case management progress notes, and
discharge summary when applicable (Summers, 2016). When a counselor does not properly
record-keep, they can face several consequences depending upon the severity. Mild
consequences include facing a fine and suspension of licensure to severe consequences such
as revocation of licensure, fines, and criminal charges.
Taylor
Contra Costa Behaviroal Health. (2021). Clinical Documentation Manual. Retrieved
from
www.cchealth.org/mentalhealth/clinical-documentation/pdf/clinical-
documentation-manual.pdf
Summers, N. (2016). Fundamentals of Case Management Practice: Skills for the Human
Services, 5th ed. Belmont, CA. Cengage Learning. ISBN-13:
9871305094765
